Cutaneous vesicostomy revisited--the second 15 years.

UNLABELLED: The aim of this paper was to review the authors' experience with cutaneous vesicostomy (CV) over the last 15 years including indications, results, and complications of CV. MATERIALS AND METHODS: The records of 31 patients treated by CV between 1987 and 2002 were reviewed. There were 20 boys and 11 girls. The two main primary pathologies were neuropathic bladder (19 patients) and posterior urethral valve (PUV) (7 patients). All patients underwent a Blocksom-type operation at a mean age of 23 months (range 14 days-9 years). Pre- and postoperative conventional uromanometry was performed in 18 patients (58%) and bladder function was assessed. RESULTS: In 23 patients (74%) the CV provided a successful diversion with improvement of the upper urinary tract and/or stabilization of the renal function. In 5 patients (16%) with PUV, the improvement was temporary. In 3 patients (10%) the CV did not result in an improvement. Twenty-four patients underwent CV closure after a mean duration of 23 months (range, 1 month-7 years) of diversion. In 2 patients with myelomeningocele (MMC) and severe somato-mental developmental delay, CV was not closed and is being considered as a permanent treatment option. Urodynamic studies in 5 PUV patients showed impaired compliance and high intravesical pressure following a successful valve ablation and closure of CV. In the neuropathic bladder group the bladder function improved following closure of CV and commencement of anticholinergic medication and clean intermittent catheterization (CIC). Our augmentation ratio in the neuropathic bladder group was 22%. Complications of CV included: stenosis in 7 patients (22%), prolapse in 2 (6%), and cellulitis in 2 (6%). The revision rate was 16%. CONCLUSIONS: In young infants CV had a less favourable result in the PUV patients than in cases with high-pressure neuropathic bladder with upper tract dilatation and severe urinary tract infection (UTI), where CV provided decompression and prevented deterioration of the renal function. Cutaneous vesicostomy has stood the test of time in our changing paediatric urological practice and it remains a valuable weapon in the armoury of paediatric urologists in selected patients.

Metabolic findings after colocystoplasty in children.

OBJECTIVES: To investigate whether colocystoplasty has resulted in metabolic changes in the growing child during long-term follow-up according to whether cecum with ascending or sigmoid colon was used. METHODS: Twenty-eight patients (mean age at surgery 11 years) were included in the study and divided into two groups: group 1, cystoplasty with cecum and ascending colon (12 patients) and group 2, sigmoid cystoplasty (16 patients). Patients' linear growth, body mass index, and the following parameters were estimated before surgery and at 3, 6, and 12 months, and then yearly after surgery: blood and urine electrolytes (sodium, potassium, chloride, calcium, phosphorus, magnesium), creatinine, urea, blood gases, blood pH, urine pH, and blood alkaline phosphatase (ALP). All the data were statistically analyzed. RESULTS: In group 1, the blood ALP increased significantly (P = 0.026) during follow-up. Severe metabolic acidosis with or without hyperchloremia was found in 7 patients. In group 2, the serum sodium and serum calcium levels decreased significantly (P = 0.014 and P = 0.003, respectively); however, the blood ALP, urine sodium, and urine phosphorus levels increased significantly (P = 0.033, P = 0.027, and P = 0.026, respectively) during follow-up. A statistically significant decrease in blood pH (P = 0.022) was found after surgery. Severe metabolic acidosis with or without hyperchloremia was detected in 5 patients. The average linear growth decreased significantly (P = 0.001 and P = 0.016, respectively) 1 and 2 years postoperatively. CONCLUSIONS: The statistically significant increase in blood ALP and decrease in serum calcium indicate bone demineralization after colocystoplasty. Our investigations in children suggest that bone demineralization is more frequent after sigmoid cystoplasty than after the use of cecum and ascending colon.

Histological findings after colocystoplasty and gastrocystoplasty.

PURPOSE: We conducted a prospective, long-term assessment of the histological changes that can occur following bladder augmentation with colon or stomach. MATERIALS AND METHODS: Histological evaluations of biopsies from 44 consecutive patients undergoing augmentation (colocystoplasty in 26, gastrocystoplasty in 18) were performed. Patients underwent endoscopic assessment and tissue sampling at 2 or 4-year intervals following the initial augmentation procedure. Patients with less than 2 years of followup were excluded from the analysis. Specimens were taken from the native bladder, the augment segment (large bowel or stomach) and the anastomotic line. Sections (4 mu.) were examined using standard histological staining methods (hematoxylin and eosin and periodic acid-Schiff) and immunohistochemistry was performed for different markers of neoplasia, cellular proliferation and blood group antigens. Histological findings were correlated with the incidence of stone formation and urinary tract infection. RESULTS: Group 1 consisted of 20 patients undergoing colocystoplasty who met the criteria for study inclusion. Of the patients 10 (50%) had stones, 19 (95%) had a positive urine culture and 6 had no histological changes. While no cases of malignancy were identified, other forms of pathological change were noted in 14 of the 20 patients (70%). Group 2 included 15 patients undergoing gastrocystoplasty who met the criteria for study inclusion. No stones or malignancy were identified in this group. Positive urine cultures were recorded in 2 patients (13%), no histological changes were found in 6 and 9 (60%) had pathological changes. CONCLUSIONS: Periodic prospective biopsy evaluation of children who have undergone either colocystoplasty or gastrocystoplasty failed to reveal any histological evidence of malignancy after 10-year followup. However, histological evidence of a premalignant lesion 13 years after followup suggests that screening for premalignant lesions should be initiated no later than 6 to 10 years following enterocystoplasty.

Colorectal carcinoma in children and adolescents--a report of seven cases.

Between 1981 and 1997 seven children and adolescents (5 boys and 2 girls) were treated for colorectal carcinomas in two paediatric centres. The case notes of the patients were studied to determine the presentation, clinical findings, prognosis and the differences of colorectal carcinomas in the young patients compared to adults. Carcinoma of the colon and rectum is uncommon in this age group and has a poor prognosis. The age range was 9 - 15 years, mean age 11.8 years. All segments of the large bowel were represented as sites of the primary tumour. Vague abdominal pain, vomiting and weight loss were the commonest presenting symptoms. The duration of symptoms varied from one month to twelve months (median: four months). Contrast enema was the most useful diagnostic investigation. Five patients had Dukes' stage C and two had Dukes' stage D tumour. Mucin-secreting adenocarcinoma was the commonest histological diagnosis. Five patients had complete resection, two had palliative procedures. Post-operative chemotherapy was given to six patients and two had post-operative radiotherapy.